PHC - Memorial Hospital



Required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)




On the last page of this document is the name and phone number of the Facility Privacy Officer should you have questions about your privacy rights. You will also find the effective date of this document and, in addition to the hospital, the other healthcare providers that may follow this notice.



This notice describes our hospital?s practices and that of (1) any healthcare professional authorized to enter information into your hospital chart; (2) all departments and units of the hospital; (3) any member of a volunteer group we allow to assist you while you are in the hospital; and (4) all employees, staff and hospital personnel.


Each time you visit a hospital, physician, or other provider of health care, a record is made of your visit. We need this information to provide you with quality care and to comply with the law.  Your health record is the physical property of the healthcare provider that compiles it; however, the information belongs to you.  We are required by law to maintain the privacy of your health information and we are committed to doing so.  We will abide by the terms of this notice as required by federal law.



Treatment.  Medical information is used to provide you with medical treatment.  This information may be disclosed to physicians, nurses, and other individuals who are involved in your care. Departments of the hospital may share information about you to coordinate the things you need, such as prescription drugs, lab tests and X-rays.  For example, a physician treating you for a broken bone will need to know if you are diabetic as this may slow the healing process.  The physician may need to tell the dietitian about the diabetes so appropriate meals can be provided.

Payment.  We use and disclose medical information about you so that we can bill and collect payment.  This could include an insurance company or a third party.  If you are covered by health insurance your health plan may need information from us about a surgery or other procedure you had, or will have, before they will pay us. We may disclose information about you for the payment activities of another healthcare provider.

Health Care Operations.  Your medical information may be used or disclosed for purposes of our day-to-day operations.  These activities are necessary to operate the hospital and to monitor the quality of care our patients receive.  Examples would include to assess your satisfaction with our services; remind you of appointments; to tell you of possible treatment alternatives; evaluation of the treatment you received by our staff; to work with health oversight organizations which would include audits, investigations, inspections and licensure; and to combine information about you with other patients to determine what additional services should be provided.

Clergy.  In accordance with the law, we may disclose your name, location in the facility, religious affiliation and general condition to members of the clergy, but only if you have not objected to this information being released.

Individuals Involved in Care or Payment for Your Care.  We may disclose your medical information to a family member or friend who will be involved in your care.

Law Enforcement.  Subject to certain restriction, we may disclose information required by law enforcement.

Legal Requirements.  We disclose patient information to comply with both state and federal laws.  For example, we are required to report to the state anytime a patient has certain diseases, for example, tuberculosis.  Other examples of required reporting would involve cases involving abuse, negligence or domestic violence; Workers Compensation Agents; Food and Drug Administration; Correctional institutions regarding inmates; to comply with court orders, subpoenas, or other administrative process; organ procurement organizations; and to reports to the state all births and deaths.

Medical Examiners, Coroners, and Funeral Directors.  We may disclose information to these entities when necessary for them to carry out their job responsibilities.

Military and Veterans.  If you are, or have been, a member of the armed forces we may disclose information about you as required by military authorities.

National Security.  We may release patient information to authorized federal officials for matters related to national security.

Patient Directory.  You have the opportunity to be included in the patient directory or you may ?opt out.?  If you are in the patient directory and someone asks about you by name then we may provide verification that you are a patient, your location in the facility, and your general condition (for example, fair, stable, etc.). Should you decide to opt out of the directory then anyone asking for you will be given no information. 

Serious Threats to Health or Safety.  We may disclose information about you when necessary to prevent a serious threat to your health and safety as well as the health and safety of the public.

Public Health Risks.  We disclose information to report reactions to medications or medical products; to notify people of recalls; to notify people who may have been exposed to a disease or at risk of contracting or spreading a disease; and to report certain injuries as gunshots or knife wounds.



You have the following rights with regard to your health information. Please contact the privacy officer to obtain the appropriate forms for exercising these rights.


To Inspect and Copy.  In most cases you have the right to inspect and to obtain a copy of the health information that may have been used to make decisions about your care.  A fee may be charged if you obtain a copy of your records.  The law provides in limited circumstances you may be denied access to this information.

To Request an Amendment to Your Medical Record.  If you believe that the information we have about you is incorrect or is incomplete, you have the right to request an amendment to the information.  You have this right for as long as we have the information.

To Request Restrictions.  You have the right to request that we restrict or limit the medical information we use or disclose about you for treatment, payment, or healthcare operations.   The law states we are not required to comply with your request; however, if we do then we will comply unless the information is needed to provide you with emergency care.

To Request Confidential Communications.  You have the right to request that we communicate with you about medical matters in a certain way or at a particular location. We will accommodate all reasonable requests; however, you are not allowed to limit the way we can contact you in order to avoid your responsibility to pay us for the services rendered to you.

To Request an Accounting of Disclosures.  You may request a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or health care operations.   We are not required to provide for an accounting which took place before April 14, 2003.



If we wish to disclose medical information about you for a reason not covered by treatment, payment, healthcare operations, legal requirements or other disclosures as set forth in this notice, we will seek your written authorization.  If you provide us written authorization to use or disclose medical information about you, you may revoke it at any time by doing so in writing. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.



We reserve the right to change this notice and our policies at any time.  If our policies change and we make changes to our Notice then we will post the new Notice in a public area.  You can request a copy of our Notice at any time.



If you believe your privacy rights have been violated, you may file a complaint with the Facility Privacy Officer or with the Secretary of the Department of Health and Human Services in Washington, D.C.  To file a complaint you will need to contact the Facility Privacy Officer whose name and phone number is below.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.




If you have questions, requests, or complaints, please contact:


Jeffrey J. Butker                                                                     Dawn E. Moser

P.O. Box 4788                                      or                               P.O. Box 4788

Martinsville, VA 24115-4788                                                    Martinsville, VA 24115-4788

(276) 666-7491                                                                        (276) 666-7597



This hospital and the physicians who practice at the hospital are independent contractors and do not hereby assume any liability for the services or conduct of each other.



The Effective Date of this Notice is April 14, 2003.



HomeCare of Memorial Hospital (offices in Martinsville and Stuart)

Hospice of Memorial Hospital

MH Primary Care Internal Medicine

MH Primary Care Family Practice

Prenatal Clinic

320 Hospital Drive, Martinsville, Virginia  24115     (276) 666-7200